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Report Writing. Robert Tatum, DC, DACBR Associate Professor Radiology Diagnosis Department Palmer College of Chiropractic. Jean Martin Charcot, 1825-1893 “Disease is very old and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.”

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Report writing
Report Writing

Robert Tatum, DC, DACBR

Associate Professor

Radiology Diagnosis Department

Palmer College of Chiropractic


Jean Martin Charcot, 1825-1893

“Disease is very old and

nothing about it has changed.

It is we who change as we

learn to recognize what was

formerly imperceptible.”

De L’Expectation en Medicine

Turn everything into an “Aunt Minnie” whenever possible by looking at films, looking at films, and looking at films


Provide reliable anatomical, morphological & physiological information to effect treatment

Treatment should be better than the natural history of the disease



Diagnostic accuracy in the interpretation of abnormal lumbosacral radiographs

Chiropractic Radiologists

Skeletal Radiologists (Medical)

Chiropractic Radiology Residents

General Medical Radiologists

Medical Radiology Residents

Medical Clinicians

Chiropractic Clinicians

Chiropractic Students

Medical Students

Diagnostic Accuracy in the Interpretation of Abnormal Lumbosacral Radiographs

71

70

62

52

45

31

28

20

6

0

10

20

30

40

50

60

70

80

John AM Taylor DC DACBR et al

Spine Vol 20 No 10 1995


Report writing1
Report Writing

  • part of the patient’s medicolegal record

  • provides a comparison with previous or later examinations

  • provides a record if radiographs are lost

  • resume of contraindications or indications

  • evaluate radiographs in the proper environment

  • develop a consistent search pattern


The reading room
The Reading Room

  • Should be quiet and darkened without distractions.

  • Provide enough illuminators so that all films of the region In question can be viewed. This is important so that a three dimensional aspect can be perceived.

  • Hotlight examination of relatively over-exposed regions is an absolute must.

  • Remember that ALL areas within the collimated field of the radiograph are to be accounted for.


Viewboxes

chest

AP T

LatT

cspine

AP L

Lat L

Viewboxes

  • have enough to view all the anatomy at onetime

  • at least two 4 over 4’s

  • hot light …an absolute necessity


Viewing equip and resources
Viewing equip. and resources

  • View stations

  • Hot light

  • Ruler

  • Magnifying Glass

  • Textbooks


Image presentation
Image Presentation

Chiropractic/Surgical

Anatomic




Report writing2
Report Writing

  • reports should contain the following items

    heading

    clinical information *(debatable)

    findings

    diagnosis/differential diagnosis/conclusions

    recommendations

    signature


Report writing3
Report Writing

  • every radiographic examination MUST have a radiology report generated

  • heading: date of exam, date of report, patient information, views

  • clinical information may help with the clinical/radiological correlation but it is debatable on its use in reports


Report writing4
Report Writing

  • findings: a description of what you see written in paragraph full sentence format, utilizing the “ABC’S”

  • impression or diagnosis (DDx) or conclusions listed 1,2,...

  • recommendation: further diagnostic studies or referral

Last paragraph of incidental stuff


Findings
Findings

  • the body of the report

  • contains a written description of the relevant normal and abnormal findings

  • using full sentence paragraph format

  • does not contain diagnoses

  • usually divided into the “ABCS”; “BCAS”, etc

  • used as a SEARCH pattern

  • use a flexible search pattern, particularly of related signs


Findings1
Findings

  • A: alignment (C,T, L)

  • B: bone (C,T, L)

  • C: cartilage (C,T, L)

  • S: soft tissues (C, T, L)

  • Cervical ABC’S

  • Thoracic ABC’S

  • Lumbar ABC’S


Findings2
Findings

  • Decreased anterior vertebral body height is noted at C-7.

  • A small osteophyte is noted at the anterior inferior aspect of C-5 and possibly C-4. Slight sclerosis is noted involving the C-7/T-1 posterior joints. There is slight decreased disc height noted at the C4-C-7 levels.


Findings3
Findings

  • The cervical lordosis is reduced. Slight anterior weight bearing is noted involving the cervical spine.

  • The prevertebral soft tissues and the remaining soft tissues are within normal limits.

  • Incidentally noted is an artifact overlying C-1


Impressions
Impressions

  • Compression fracture at C-7. (discuss new, old, unknown age, etc)

  • Early DDD at C-4 thru C-7 with early posterior joint arthrosis at C-7/T-1.

  • Cervical hypolordosis

  • Slight anterior weight bearing


Recommendations
Recommendations

  • Depends on if you know if it is new, old or unknown

  • New: An orthopedic consultation is needed. With Specialized imaging as needed.

  • Unknown: Review old films, history, clinical information and special imaging as needed

  • Old: Correlate clinically with follow up studies as needed.


Findings4
Findings

  • does not have to follow the ABC’S format but may be BCAS, SBAC, etc

  • try to do clinically relevant stuff first

  • it is a search pattern to look at the entire film

  • if the B and the C category are both degenerative/arthritic it is okay to put them together into the same paragraph (eg, osteophyte and decreased disc height at C-5=DDD)



Related findings of a pathological or disease process can go and probably should go in the same paragraph

eg, you might combine a

B and a C

or a B and A

or a B and an S

or an S and a B

or a BAS,

Or a BASC

etc etc etc


If related BCAS stuff are combined into a related BCAS type paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

e.g.,

If you do an arthritic related BC paragraph you would still need a separate B and a separate C paragraph for all non related (non arthritic) B and C stuff


DEMANDS paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

X

  • The clinic wants you to use the BCAS format if possible (based on clinical relevance.)

  • Bony and cartilage changes usually influence alignment changes

BC, B, C, A, S

Or

B, BC, C, A, S

Or

BCS, B, C, A, S

Or etc


The clinic demands you to use the bcas format if possible based on clinical relevance
The clinic demands you to use the paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuffBCAS format if possible (based on clinical relevance.)


Findings6
Findings paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • try to use commonly accepted terminology

  • do not use “listings”

  • try to be as descriptive as you can

  • someone should be able to achieve the diagnosis by just reading your findings

  • some findings are also a diagnosis

  • the cervical lordosis is reduced (finding)

  • cervical hypolordosis (dx)


Impressions1
Impressions paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • diagnoses or differential diagnoses

  • listed numerically 1, 2, 3,…..

  • listed in order of clinical significance

  • order of significance at times is debatable

  • cervical hypolordosis vs lumbar curve

  • short precise statements (dx/ddx)

  • try to be specific and grade conditions

  • mild degenerative disc disease at C5, etc


Impressions2
Impressions paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • sometimes a finding will be repeated as a diagnosis

  • sometimes you may not be sure of a diagnosis and you would repeat the finding with qualifiers such as suggestive of... or consistent with..., etc (pathologic fx)

  • last impressions are things that are “incidentally noted” such as ponticle, etc


Impressions3
Impressions paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff


Recommendations1
Recommendations paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • further tests that may be needed to support or clarify a diagnosis

  • lab studies

  • specialized imaging

  • concurrent consultations or referrals

  • technical comments

  • do not include chiropractic case management options


Recommendations2
Recommendations paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff


Report writing5
Report Writing paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • spine studies need a single report

  • extremities and chest need separate reports

  • reports must be signed by the doctor that generates the report


Report writing chest
Report Writing paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuffChest

  • SBCA

  • Is the technique

    okay


Report writing chest1
Report Writing/Chest paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • if no abnormalities are detected

  • your report would stress the normal findings

  • “SBCA” type format….chest example

  • The mediastium is midline and there is no evidence of cardiomegaly. The costophrenic angles are clear. The lung fields are well aerated and without evidence of mass lesion or infiltrate. Visible infradiaphragmatic soft tissues are unremarkable. The visualized soft tissues of the thorax are within normal limits.


Report writing chest2
Report Writing/Chest paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

  • The bone density is adequate. The osseous structures unremarkable and the visualized joint spaces are within normal limits.

  • A slight right thoracic curvature is noted.

  • Conclusions:

  • 1.No definitive abnormalities of the chest are detected

  • 2. Slight right thoracic curvature

  • Or:

  • 1. No definitive abnormalities of the chest are detected

  • other than a slight right thoracic curvature

  • Recommendations:



If everything is normal paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff

STRESS the positives

Using the “ABCS” type format or “BCAS”

Talk about what you should be looking at using the search patterns


68 year old with unrelenting neck pain and upper extremity numbness

Findings, Diagnosis and recommendations?


Chordoma numbness

68 year old with unrelenting neck pain and upper extremity numbness

Findings, Diagnosis and recommendations?


R numbness

Impressions:

1.

2..

Recommendations:

1. Review prior films if available, BCP and MRI examination as needed.


R numbness


Most pathology will
Most pathology will numbness

  • Change or alter architecture/structure/anatomy

  • Increase or decrease density

The hardest part is knowing what is normal or perceived as normal

Looking at films, looking at films and by looking at films

And of course having diagnostic quality radiographs is a must


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